Preventing Central Venous Catheter Complications- An evidence based approach

Preventing Central Venous Catheter Complications- An evidence based approach Srinivas Bapoje MD, MPH Director, Hospital Medicine Procedure Service Denver Health Medical Center

Learning Objectives Discuss about various types of Central Venous Catheters (CVCs) and their indications Review complications of CV catheterization Discuss factors affecting complication rates Discuss interventions for preventing CVC related complications

Background > 5 million CVC s inserted every year 15 million CVC days/year in ICU Useful for invasive monitoring and therapeutic purposes Associated with adverse event rate that are hazardous to patients and expensive to treat (2-26%) Target area for quality improvement

Historical Perspective Unpublished reports of central venous access in early 1900 s First published work: Werner Forssmann 1929; Nobel Prize in Medicine for Cardiac Catheterization in 1956

Types of CVC s CVC: By definition tip resides in the central circulation Non-Tunneled Single or multilumen,hohn (<6 weeks), cordis etc PICC (long term) PA catheters Tunneled (long term) Groshong, Hickman catheter etc Implanted port Permacath

Types of CVC s Hohn catheter PICC

Types of CVC s Port Groshong

Indications for a CVC Therapeutic indications- Administration of chemotherapy, TPN, blood products, IV medications and fluids Hemodialysis and plasmapheresis Diagnostic indications Establishing or confirming diagnosis Establish prognosis Monitor response to treatment Repeated blood sampling

Clinical Case 1 61 y/o M with hx of enterocutaneous fistula needing 6 months of TPN A single lumen non tunneled right IJ silicone Hohn catheter placed by IR Presented six wks later to PCP with subjective fevers for a week. Two sets of blood cultures drawn in clinic grow gram negative bacilli.

Clinical Case 1 On admission pt febrile to 38.5 with a WBC count of 16.5, BP 99/60, creatinine of 2 (baseline 1) Chlorhexidine sponge absent at the catheter site Pt diagnosed with sepsis due to Central Line Associated Blood Stream Infection (CLABSI) and started on zosyn. CVC removed and tip cultured, cultures from blood and cath tip grow Klebsiella Oxytoca

Complications of CVC Infection Mechanical Thrombotic Occlusion Early (insertion) Delayed (days)

Complications of CVC Mechanical complications Complications occurring during the insertion of a CVC (< 0.1-19%) McGee D et al NEJM 2003; 348;12: 1123-33

Complications of CVC Mechanical complications Other: arrythmias, malposition, air embolism & tamponade rare but possible Cardiac tamponade (most serious) PICC : 0.5-1% (hematoma and arterial injury)

Thrombotic Complications of CVC CVC - thrombogenic and high risk for thrombosis About 50% of venous thrombosis in the ICU are catheter related Femoral (21.5%) > PICC > Internal jugular > Subclavian (1.5%) Risk of embolization Treated as a DVT as clinical significance unknown

Infectious Complications of CVC Catheter colonization Exit site infection Central Line Associated Blood Stream Infection (CLABSI)

Infectious Complications of CVC ~ 250,000 CLABSI occur each year in the US (~ 80,000 in the ICU) Incidence is 3.8-5.3 /1000 catheter days in the ICU Attributable mortality from CLABSI- 12%-25% Attributable cost/infection- $ 6,000- $ 40,000 (higher in the ICU) Increased length of stay

Complications of CVC

Complications of CVC Mechanisms of infection Maki DG, Hospital Infections, Little Brown & Co, 1992

Complications of CVC Catheter Occlusion Usually considered as a minor complication Fibrin sheath or thrombus formation at the tip of the catheter PICC (0.4)> CVC (0.08)> Port, Tunneled CVC (0.04) (event rate/1000 catheter days) Moureau N et al JVIR 2002;13:1009-16

Strategies for Preventing Central Venous Catheter Complications- What s the Evidence? =

Clinical Case 2 59 y/o F in the MICU with copd, multi-focal pneumonia causing septic shock and resp failure on mechanical ventilation needs a CVC for pressors and antibiotics. The intern asks what is the best CVC site for her and the maximum number of attempts he could try to insert the CVC. a) Right subclavian with 4 passes b) Left IJ with 2 passes c) Right femoral with 5 passes d) Right IJ with 3 passes

Preventing Mechanical Complications Patient factors Insertion at a site of scarring, surgery or skeletal deformity Coagulopathy, obesity, volume depletion uncooperative/delirious pt etc Operator factors Failure to insert after three attempts increases risk by six times (Mansfield, NEJM 1994;331:1735-38) Operators with 50 insertions have 50% less complications (Sznajder JI, Arch IM1986;146:259-261)

Preventing Mechanical Complications Avoid femoral catheterization Twice as high complications compared to Subclavian or IJ approach (Merrer J JAMA 2001;286:700-707 ) No role for routine catheter site change 9% risk of mechanical complications (Cobb DK,NEJM 1992;327:1062-68 ) Simulation based training Decreased risk of arterial punctures and higher success rate (Barsuk JH et al, Crit Care Med. 2009 Oct;37(10):2697-701)

Preventing Mechanical Complications Use Ultrasound during insertion Associated with decreased risk for mechanical complications during IJ CVC placement (Randolph AG, Crit Care Med 1996;24:2053-58. ) IJ Carotid

Preventing Mechanical Complications Use Ultrasound during insertion Increased successful cannulation in internal jugular approach by 10% Reduced incidence of arterial puncture from 8.3% to 1.7% Average access time reduced by a factor of 4 Ultrasound visualization of subclavian vein more difficult and has not been shown to reduce complications (Denys BG, et al. Circulation. 1993;87:1557-62.)

Preventing Mechanical Complications Pneumothorax Consider IJ placement to decrease the risk Insert on the ipsilateral side of a chest tube Air embolism Occlude catheter hub at all times and patient placed in Trendelenberg position Cardiac tamponade and arrhythmia Consider placing CVC outside of the pericardial silhouette

Preventing Central Line Associated Blood Stream Infections (CLABSI)

Clinical Case 3 35 y/o M with dilated CM in the ICU with chf needing dobutamine, the nurse requests a central line. What is the best recommended practice to decrease the chance of a line infection. a) Place rt subclavian with chlorhexidine prep and a small drape and sterile glove b) Place lt IJ with povidone prep and maximal barrier precuations c) Place rt subclavian with chlorhexidine prep and maximal barrier precautions d) Place right femoral with chlorhexidine prep and maximal barrier precautions

Preventing CLABSI Independent risk factors Prolonged hospitalization before catheterization Prolonged duration of catheterization Heavy microbial colonization at the insertion site Heavy microbial colonization of the catheter hub Internal jugular and femoral catheterization Neutropenia Total parenteral nutrition Substandard care of the catheter (excess manipulation) Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

Operator factors Preventing CLABSI Hand hygiene: No RCT s comparing hand washing to no hand washing but good practice! Achieved either by alcohol based products or antibacterial soap with adequate rinsing RCT comparing the two found similar rate of surgical site infection 2.44% vs. 2.48% (alcohol vs. soap) 95% CI 0.88, 0.96 p <0.001

Effect of catheter material Evidence lacking Preventing CLABSI Anecdotal and lab reports suggest that Silicone catheters associated with a higher risk compared to Polyurethane Sherertz RT et al Contribution of vascular catheter material to the pathogenesis of infection: the enhanced risk of silicone in vivo. J Biomed Mater Res. 1995 May;29(5):635-45.

Site of placement Preventing CLABSI Subclavian site lowest risk for CLABSI with highest risk for femoral site (4.5% vs 19.8) (Merrer J, JAMA. 2001 Aug 8;286(6):700-7) Consider tunneled catheter or PICC for long term access Implanted Port has the lowest risk (O Grady, MMWR Aug 9, 2002, Vol 51)

Preventing CLABSI Role of Antibiotic Impregnated Catheters- RCT s: 1. CVC with chlorhexidine & silvadene vs no coating; Maki DG et al Ann Intern Med 1997;127:257-66. * 7.6 infections/1000 cath days (5 %)---- 1.6/1000 cath days (1%), RR 0.21 95% CI 0.03, 0.95 p = 0.03 2. CVC coated with rifampin & minocycline vs no coating; Raad et al Ann Intern Med 1997;127:267-74. * 7.3 infections/1000 cath days ( 5%) ---- 0/1000 cath days (0%), p < 0.01

Meta-analysis of CLABSI Rates with Chlorhexidine+ Silvadene coated CVC Tennenberg Maki Hannan Bach Heard Collin Ciresi Pemberton Ramsay Trazzera George Summary OR 0.56, 95% CI (0.37-0.84) 0.0 0.5 1.0 2.0 3.0 Odds Ratio Veenstra DL et al. JAMA 1999 281(3):261-267

Preventing CLABSI Cost effectiveness of Antibiotic Catheters Cost effectiveness study of chlorhexidine + silvadene impregnated catheters Decrease in CLABSI by 2.2 % and cost saving of $ 196 per catheter Consider when the institutional rate of the CLABSI is > 2.2%

Preventing CLABSI Effect of multi lumen catheters Lack of RCTs comparing number of lumens Multiple observation studies show increased risk with more lumens: ~3.7 % (single) vs. ~ 7% (triple) 1. Early TF et al, Increased infection rate in double-lumen versus singlelumen Hickman catheters in cancer patients. South Med J. 1990;83:34-6. 2. Hilton E et al, Central catheter infections: single- versus triple-lumen catheters. Am J Med. 1988;84:667-72. 3. Yeung C, May J, Hughes R. Infection rate for single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol. 1988;9:154-8.

Effect of multi lumen catheters CLABSI common in multi lumen CVC (OR, 2.15; 95% CI 1.00-4.66), catheter colonization was not (OR, 1.78; 95% CI, 0.92-3.47) Analysis of studies of higher quality showed no effect on CLABSI (OR 1.30; 95% CI 0.50-3.41) Evidence equivocal, IDSA recommends using CVC with minimum number of lumens as needed Dezfulian C et al Rates of infection for single-lumen vv. multilumen CVC: a meta-analysis Crit Care Med. 2003 Sep;31(9):2385-90.

Preventing CLABSI Role of sterile barriers A RCT using maximal sterile barrier (sterile gloves, caps, gown, mask and full body large drape) vs. sterile gloves and small drape decreased rate of infection from 7% to 2% (p= 0.03) Cost saving of $ 167 per catheter Similar results and cost savings found on another clinical and cost effective analysis 1. Raad et al; Prevention of CVC Related Infections using maximal sterile barrier precautions, Infect Control Hosp Epidemiol 1994;15:231-8 2. Hu KK et al, Use of maximal sterile barriers during CVC insertion: clinical and economic outcomes. Clin Infect Dis. 2004 Nov 15;39(10):1441-5.

Antibiotic ointments Preventing CLABSI No affect on the rate of CLABSI Promotes fungal colonization and drug resistant bacteria Maki DG et al. A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection. Am J Med 1981;70:739-44.

Preventing CLABSI Routine scheduled catheter changes Two RCTs evaluated a routine q7 day change in catheters No reduction in rates of CLABSI Eyer S et al, Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990;18:1073 9. Uldall PR et al, Changing subclavian haemodialysis cannulas to reduce infection. Lancet 1981;1:1373..

Routine guidewire catheter changes Associated with a trend towards increased risk of CLABSI but fewer mechanical complications Cook D et al. CVC replacement strategies: a systematic review of the literature. Crit Care Med 1997;25:1417-24.

Preventing CLABSI Role of skin antisepsis A RCT compared 2% chlorhexidine gluconate vs. 10% povidone iodine or 70% ethyl alcohol CLABSI rate of 0.5% (chlorhexidine group) vs 2.3% and 2.6% (povidone iodine and ethyl alcohol respectively) OR 0.16 p = 0.04 2% Chlorhexidine superior to other antiseptic solutions Maki DG et al, Prospective RCT of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with CVC. Lancet 1991;338:339 43.

Role of skin antisepsis A meta-analysis also demonstrated superiority of chlorhexidine over povidone iodine Chaiyakunapruk N et al, Chlorhexidine Compared with Povidone- Iodine Solution for Vascular Catheter Site Care: A Meta-Analysis, Ann Intern Med, 2002; 136: 792-801

Role of dressing material A meta-analysis of RCT s of studies comparing polyurethane transparent dressing vs. gauze Trend towards increased infection with transparent dressing but statistically insignificant Hoffmann KK et al. Transparent polyurethane film as an intravenous catheter dressing: a meta-analysis. JAMA 1992;267:2072 6.

Role of Chlorhexidine impregnated sponge (Biopatch ) Multicenter RCT compared Biopatch vs. routine standard of care in 589 subjects 44% reduction in local infection ( p< 0.0001) 60% reduction in CLABSI Intervention No CLABSI rate (%) CLABSI rate (%) Biopatch 288 (97.6) 7 (2.4) Control 276 (93.9) 18 (6.1) Total 564 25 (P = 0.026) Maki DG et al. Toronto, Ontario: American Society for Microbiology, 2000.

Preventing CLABSI Role of systemic antibiotic prophylaxis Oral or parenteral antibiotics have no effect on the incidence of CRBSI among adults 1. McKee R et al; J Hosp Infect 1985;6:419 25. 2. Ranson MR et al; J Hosp Infect 1990;15:95 102. 3. Ljungman P et al ; Support Care Cancer 1997;5:485 8.

Preventing CLABSI Role of disinfection of catheter hubs Disinfecting catheter hubs with friction for 15 secs using either 70% alcohol or chlorhexidine/alcohol solution associated with decreased bacterial colonization Kaler W et al, Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction, Journal of Association of Vascular Access, 2007

Preventing CLABSI Role of evidence based interventions Landmark cohort study in 106 ICU s in Michigan Intervention using five evidence based procedures to reduce CLABSI

Preventing CLABSI Role of evidence based interventions Procedures: hand washing, using full-barrier precautions during insertion of CVC, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. Median CLABSI rate decreased from 2.7/1000 cath days to 0/1000 cath days at 3 months (p 0.002) Mean CLABSI decreased from 7.7/1000 cath days to 1.4/1000 cath days at 16-18 months of follow up 66% reduction of CLABSI at 18 month period

Evidence based interventions at Denver Health

Clinical Case 1 Patient discharged six days later on 10 days of oral levaquin after blood cultures cleared with a Groshong (tunneled) catheter. Key risk factors in this case: IJ placement, Hohn catheter, lack of catheter site care, TPN

Preventing Thrombotic Complications Site of insertion Subclavian insertion lowest risk for thrombosis (Merrer J JAMA 2001;286:700-707 ) ( Hamilton HC et al, Cochrane Datab Syst Review, 2007 Jul 18; (3) Role of anticoagulants in prophylaxis Possible benefit in a systematic review for use of low dose warfarin and low dose LMWH in patients with solid tumors (Klerk CP, Arch IM 2003 Sep 8;163(16):1913-21) Consider heparin bonded catheter in high risk pts

Conclusions CVC complications are hazardous to patients and expensive to treat Practice evidence based guidelines to reduce complication rate Assess need for CVC daily and remove if not needed Make institutional commitment to eliminate complications Offer training courses in central line placement Follow complication rates and provide feedback

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